Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure residents and resident's representatives were
invited to care plan conferences to develop and revise comprehensive care plans with the facility's
interdisciplinary team. The facility also failed to initiate and update care plans to address resident's
significant weight loss and episodes of refusing care.
This applies to 3 of 3 residents (R1, R3, R4) reviewed for policy and procedure in the area of care plan
coordination in the sample of 5.
The findings include:
1. On April 26, 2023 at 3:44 PM, R1 was lying in bed. R1 was not able to answer questions due to her
cognitive status.
The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and transferred to
the local hospital on April 18, 2023. R1 returned to the facility on April 27, 2023. The EMR continues to
show R1 has multiple diagnoses including, cerebral infarction, myocardial infarction, heart disease,
occlusion and stenosis of the right carotid artery, chronic congestive heart failure, PVD (Peripheral Vascular
Disease), anxiety disorder, diabetes, bradycardia, dementia, and aphasia.
R1's MDS (Minimum Data Set) dated January 17, 2023 shows R1 has severe cognitive impairment,
requires supervision with bed mobility, transfers between surfaces, locomotion on the unit, eating and
personal hygiene, limited assistance with walking in the room and corridor, locomotion off of the unit, and
dressing, and extensive assistance with toilet use and bathing. R1 is frequently incontinent of urine, and
occasionally incontinent of stool.
On December 6, 2022, V3 (Social Service Assistant) documented a care plan meeting was held with the
facility's IDT (Interdisciplinary Team), R1 and V10 [Sister of R1].
The facility does not have documentation to show a care plan meeting was held for R1 after December 6,
2022.
Facility documentation shows R1 had a significant weight loss of 7.86 percent between October 24, 2022
and January 13, 2023, when R1's weight declined from 136.2 pounds on October 24, 2022 to 125.5 pounds
on January 13, 2023. The facility does not have documentation to show care plan interventions were
initiated to address R1's significant weight loss on January 13, 2023.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 12
Event ID:
145699
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145699
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara of Elgin
1950 Larkin Avenue
Elgin, IL 60123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
The facility's records show R1 continued to experience monthly weight loss. On April 14, 2023, R1 weighed
112.9 pounds, a 17.11 percent weight loss between October 24, 2022 and April 14, 2023. The facility does
not have documentation to show care plan interventions were initiated to address R1's ongoing, significant
weight loss.
Shower sheets for R1 show R1 received a shower on February 8, 9, and March 23, 2023. R1 refused
showers and/or bed baths on the following dates:
February 2, 15, 23, 26, 2023, March 6, 11, 20, 27, 2023, and April 3, 6, and 10, 2023.
The facility does not have documentation to show a care plan to address R1's refusal of care, specifically
showers. The facility does not have documentation to show V10 [Sister of R1] was notified of R1's refusal of
care or possible interventions to address R1's refusal of showers.
On April 26, 2023 at 9:05 AM, V10 (Sister of R1) said, I have not had a care plan meeting at the facility
since December 2022. No one notified me about her significant weight loss. I only found out when she was
hospitalized on [DATE]. I do not believe she has had a shower since she was admitted in October 2022. No
one has ever contacted me regarding her refusal of showers or how we can brainstorm for ideas to get her
to shower or to eat more. We should have had a care plan meeting to address all of these concerns.
2. On April 27, 2023 at 12:35 PM, R3 was lying in bed. R3 was not able to be interviewed due to his
cognitive status. V11 (Spouse of R3) was sitting in a chair next to R3. V11 said she had not been invited to
a care plan meeting regarding R3's care needs since his admission on [DATE]. V11 continued to say she
was concerned because R3 appeared to have lost a lot of weight and no one had contacted her regarding
his weight loss or possible interventions to prevent further weight loss. He was eating pureed food for a
while, and he did not like that. I brought in my own diet supplement drinks and meal bars for him because
those are his favorite. I did tell someone that he really likes ice cream, but they don't always bring it to him.
The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including,
non-traumatic subdural hemorrhage, depression, altered mental status, dysphagia, unsteadiness on feet,
abnormal gait, lack of coordination, abnormal posture, cognitive communication deficit, aphasia, falls, atrial
fibrillation, dementia, and elevated white blood cell count.
R3's MDS (Minimum Data Set) dated March 21, 2023 shows R3 has severe cognitive impairment, is totally
dependent on facility staff for dressing and personal hygiene and requires extensive assistance with all
other ADLs (Activities of Daily Living). R3 is always incontinent of bowel and bladder.
On March 17, 2023 at 10:58 AM, V7 (Dietitian) documented R3's admission weight of 124.7 pounds,
classified R3 as underweight, and recommended a house supplement twice a day.
Facility documentation shows the following weights for R3:
124.7 pounds - March 13, 2023
107.2 pounds - March 22, 2023
111.4 pounds - March 29, 2023
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145699
If continuation sheet
Page 2 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145699
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara of Elgin
1950 Larkin Avenue
Elgin, IL 60123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
106.4 pounds - April 12, 2023
Level of Harm - Minimal harm
or potential for actual harm
The facility's documented weights reflect a 14.68 percent weight loss between March 13, 2023 and April
12, 2023.
Residents Affected - Few
R3's care plan initiated on March 17, 2023 shows, Resident is at risk for alteration in nutritional status. R3's
care plan has multiple interventions initiated March 17, 2023, including consider finger foods, elevate head
of bed during feeding or meals if indicated, monitor for signs and symptoms of dehydration and weight loss,
monitor resident with difficulty of chewing or swallowing, assess for signs of choking and/or aspiration,
obtain labs as ordered, obtain weight as ordered, offer extra fluids if not contraindicated, provide assistance
for meals if indicated, provide diet and supplements as ordered, and provide good oral hygiene. As of April
26, 2023 at 3:37 PM, the facility did not have documentation to show new care plan interventions were
initiated following R3's significant weight loss.
As of April 27, 2023, the facility did not have documentation to show a care plan meeting was held with R3,
V11 (Spouse of R3), and the facility's IDT.
On April 26, 2023 at 1:45 PM, V7 (Dietitian) said, I am responsible for updating care plan interventions for
residents with weight loss. I did not update the care plans for [R1] and [R3]. I have not been to a care plan
meeting for either of those residents.
3. On April 26, 2023 at 3:45 PM, R4 was sitting up in her bed in her room. R4 was very confused and
unable to answer questions due to her cognitive status.
The EMR shows R4 was admitted to the facility on [DATE] with multiple diagnoses including diabetes,
major depressive disorder, psychosis, dementia, obstructive sleep apnea, anemia, and anxiety disorder.
R4's MDS dated [DATE] shows R4 has severe cognitive impairment, requires limited assistance for toilet
use and bathing, and supervision for all other ADLs (Activities of Daily Living). R4 is always continent of
bowel and bladder.
On May 25, 2021 at 4:22 PM, V12 (Social Services) documented, Left voicemail for POA (Power of
Attorney) to schedule care plan meeting.
The facility does not have documentation to show further care plan meetings were held for R4 after May 25,
2021.
The facility does not have documentation to show R4 received a bed bath or shower for the period
February 1, 2023 to April 19, 2023. Facility documentation shows R4 has refused every shower or bed bath
offered between February 4, 2023 and April 19, 2023.
As of May 1, 2023 at 12:47 PM, the facility does not have documentation to show a care plan to address
R4's refusal of care, specifically showers. The facility does not have documentation to show V13 (POA of
R4) was notified of R4's refusal of care or possible interventions to address R4's refusal of showers.
On April 27, 2023 at 1:36 PM, V1 (Administrator) said, [V3] (Social Service Assistant) was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145699
If continuation sheet
Page 3 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145699
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara of Elgin
1950 Larkin Avenue
Elgin, IL 60123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
scheduling care plan meetings. It is the social worker's responsibility to initiate care plan meetings. There
was a period of time that care plan meetings were not taking place.
The facility's Standardized admission Packet, revised January 2022 shows, Family and Resident
Participation in Care Plan Conferences: This facility conducts care planning conferences at regular intervals
in order to develop the interdisciplinary approach to the care that is delivered. Members of each
professional discipline attend care planning meetings and every aspect of care is addressed at these
meetings. Care plan meetings are utilized to discuss any changes in condition or developments related to
the Resident's well-being.
This facility encourages the participation of both residents and families in the care planning process. In fact,
participation by the resident and family is considered to be vital to the staff understanding the needs of the
resident and family. At a designated time prior to the care planning conference, both the resident and
family/authorized representative will be informed of the time and place of this scheduled meeting.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145699
If continuation sheet
Page 4 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145699
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara of Elgin
1950 Larkin Avenue
Elgin, IL 60123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure facility staff provided assistance with showers
and/or possible interventions when residents with cognitive impairment refused showers.
Residents Affected - Few
This applies to 2 of 3 residents (R1, R4) reviewed for improper nursing in the area of showers in the sample
of 5.
The findings include:
1. On April 26, 2023 at 3:44 PM, R1 was lying in bed. R1 was not able to answer questions due to her
cognitive status.
The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and transferred to
the local hospital on April 18, 2023. R1 returned to the facility on April 27, 2023. The EMR continues to
show R1 has multiple diagnoses including, cerebral infarction, myocardial infarction, heart disease,
occlusion and stenosis of the right carotid artery, chronic congestive heart failure, PVD (Peripheral Vascular
Disease), anxiety disorder, diabetes, bradycardia, dementia, and aphasia.
R1's MDS (Minimum Data Set) dated January 17, 2023 shows R1 has severe cognitive impairment,
requires supervision with bed mobility, transfers between surfaces, locomotion on the unit, eating and
personal hygiene, limited assistance with walking in the room and corridor, locomotion off of the unit, and
dressing, and extensive assistance with toilet use and bathing. R1 is frequently incontinent of urine, and
occasionally incontinent of stool.
Facility documentation for the period February 1, 2023 to April 26, 2023 shows R1 received a shower on
February 8, 9, and March 23, 2023.
Shower sheets for R1 show R1 refused showers and/or bed baths on the following dates:
February 2, 15, 23, 26, 2023, March 6, 11, 20, 27, 2023, and April 3, 6, and 10, 2023.
The facility does not have documentation to show V10 [Sister of R1] was notified of R1's refusal of care or
possible interventions to address R1's refusal of showers.
On April 26, 2023 at 9:05 AM, V10 (Sister of R1) said, I do not believe she has had a shower since she was
admitted in October 2022. No one has ever contacted me regarding her refusal of showers or how we can
brainstorm for ideas to get her to shower or to eat more.
2. On April 26, 2023 at 3:45 PM, R4 was sitting up in her bed in her room. R4 was very confused and
unable to answer questions due to her cognitive status.
The EMR shows R4 was admitted to the facility on [DATE] with multiple diagnoses including diabetes,
major depressive disorder, psychosis, dementia, obstructive sleep apnea, anemia, and anxiety disorder.
R4's MDS dated [DATE] shows R4 has severe cognitive impairment, requires limited assistance for toilet
use and bathing, and supervision for all other ADLs (Activities of Daily Living). R4 is always
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145699
If continuation sheet
Page 5 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145699
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara of Elgin
1950 Larkin Avenue
Elgin, IL 60123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
continent of bowel and bladder.
Level of Harm - Minimal harm
or potential for actual harm
The facility does not have documentation to show R4 received a bed bath or shower for the period
February 1, 2023 to April 19, 2023. Facility documentation shows R4 has refused every shower or bed bath
offered between February 4, 2023 and April 19, 2023.
Residents Affected - Few
The facility does not have documentation to show V13 (POA-Power of Attorney of R4) was notified of R4's
refusal of care or possible interventions to address R4's refusal of showers.
On April 26, 2023 at 11:00 AM, V2 (DON-Director of Nursing) said residents should receive showers twice
a week and facility staff document showers on the shower sheets.
The facility's undated shower schedule shows R1 should receive showers on Monday/Thursday in the AM
and R4 should receive showers on Wednesday/Saturdays in the PM.
The facility's Shower and Hygiene Policy, revised on 7/28/22 shows, Policy Statement: It is the policy of this
facility to ensure that resident shower/hygienic care is provided by the nursing staff to promote cleanliness,
provide comfort to the resident and observe the condition of the resident's skin. Procedures: Procedures: 1.
Administer resident shower once weekly and/or as often as necessary. Any resident who needs hygienic
care will be provided care to promote hygiene (facial, body, perineal care, etc.).3. Shower refusal by the
resident shall be relayed by the assigned CNA (Certified Nursing Assistant) to the charge nurse. 4. Nursing
staff to provide bed bath daily and PRN (As Needed) as needed.11. Documentation (Shower Log/CNA
Assignment Sheet): .d. If the resident refused the shower and/or if shower was not administered and
interventions taken e.g., bed bath/res-scheduling the shower schedule consistent to facility protocol.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145699
If continuation sheet
Page 6 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145699
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara of Elgin
1950 Larkin Avenue
Elgin, IL 60123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to follow their policy to assess and address
significant weight losses in residents, failed to notify the physician and resident representative of significant
weight loss, and failed to implement interventions to prevent future weight loss.
Residents Affected - Few
This failure resulted in R1 and R4 experiencing significant weight loss.
This applies to 2 of 3 residents (R1, R3) reviewed for improper nursing in the area of weight loss in the
sample of 5.
The findings include:
1. On April 26, 2023 at 3:44 PM, R1 was lying in bed. R1 was not able to answer questions due to her
cognitive status.
On April 27, 2023 at 9:15 AM, R1 was sitting up in her bed. Her breakfast tray was sitting on top of her
bedside table. A hard-boiled egg, toast, and oatmeal was on the plate and appeared untouched. V15
(CNA-Certified Nursing Assistant) said R1 had not eaten any breakfast. V15 attempted to feed R1 food off
of her breakfast tray. R1 refused to eat anything and V15 removed the tray from the room.
The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and transferred to
the local hospital on April 18, 2023. R1 returned to the facility on April 27, 2023. The EMR continues to
show R1 has multiple diagnoses including, cerebral infarction, myocardial infarction, heart disease,
occlusion and stenosis of the right carotid artery, chronic congestive heart failure, PVD (Peripheral Vascular
Disease), anxiety disorder, diabetes, bradycardia, dementia, and aphasia.
R1's MDS (Minimum Data Set) dated January 17, 2023 shows R1 has severe cognitive impairment,
requires supervision with bed mobility, transfers between surfaces, locomotion on the unit, eating and
personal hygiene, limited assistance with walking in the room and corridor, locomotion off of the unit, and
dressing, and extensive assistance with toilet use and bathing. R1 is frequently incontinent of urine, and
occasionally incontinent of stool.
Facility documentation shows R1 had a significant weight loss of 7.86 percent between October 24, 2022
and January 13, 2023, when R1's weight declined from 136.2 pounds on October 24, 2022 to 125.5 pounds
on January 13, 2023. The facility does not have documentation to show care plan interventions were
initiated to address R1's significant weight loss on January 13, 2023.
The facility's records show R1 continued to experience monthly weight loss. On April 14, 2023, R1 weighed
112.9 pounds, a 17.11 percent weight loss between October 24, 2022 and April 14, 2023. The facility does
not have documentation to show care plan interventions were initiated to address R1's ongoing, significant
weight loss. The facility does not have documentation to show R1's physician or family member were
notified of R1's significant weight losses.
On April 26, 2023 at 9:05 AM, V10 (Sister of R1) said, No one notified me about her significant weight loss.
I only found out when she was hospitalized on [DATE].
The EMR shows the following order for R1 dated March 22, 2023: Fortified cereal daily for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145699
If continuation sheet
Page 7 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145699
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara of Elgin
1950 Larkin Avenue
Elgin, IL 60123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
supplement. The March 2023 and April 2023 MARs (Medication Administration Records) show the following
intake documentation for R1's fortified cereal:
Level of Harm - Actual harm
March 31, 2023 - Ate 0 percent
Residents Affected - Few
April 1, 2023 - Ate 0 percent
April 2, 2023 - Ate 0 percent
April 3, 2023 - Ate 0 percent
April 4, 2023 - Refused
April 5, 2023 - Ate 0 percent
April 6, 2023 - Refused
April 7, 2023 - Refused
April 8, 2023 - Ate 10 percent
April 9, 2023 - Ate 0 percent
April 10, 2023 - Refused
April 11, 2023 - Refused
April 12, 2023 - Ate 0 percent
April 13, 2023 - Ate 0 percent
April 14, 2023 - Sleeping
April 16, 2023 - Ate 0 percent
April 17/2023 - Ate 0 percent
The EMR shows the following order for R1 dated March 22, 2023: Sugar Free Health Shake two times a
day for supplement, 4 ounces BID (Twice Daily), or Glucerna 8 ounces BID. The April 2023 MAR shows the
following intake for R1's health shake:
April 2, 2023 at 9:00 AM - Drank 50 percent
April 5, 2023 at 9:00 AM - Drank 40 percent
April 5, 2023 at 5:00 PM - Drank 10 percent
April 6, 2023 at 9:00 AM - Drank 40 percent
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145699
If continuation sheet
Page 8 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145699
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara of Elgin
1950 Larkin Avenue
Elgin, IL 60123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
April 7, 2023 at 9:00 AM and 5:00 PM - Refused
Level of Harm - Actual harm
April 8, 2023 at 9:00 AM - Drank 0 percent
Residents Affected - Few
April 10, 2023 at 9:00 AM - Refused
April 11, 2023 at 9:00 AM - Drank 50 percent
April 11, 2023 at 5:00 PM - Refused
April 12, 2023 at 9:00 AM - Drank 50 percent
April 12, 2023 at 5:00 PM - No administration documentation present
April 13, 2023 at 9:00 AM - Drank 50 percent
April 14, 2023 at 9:00 AM - Drank 80 percent
April 14, 2023 at 5:00 PM - Drank 50 percent
April 15, 2023 at 5:00 PM - Drank 40 percent
April 17, 2023 at 5:00 PM - Drank 50 percent
April 18, 2023 at 9:00 AM - Drank 50 percent
On April 26, 2023 at 1:45 PM, V7 (Dietitian) said, I have not gotten to see [R1] yet this month. When I saw
her a month or so ago, she was very happy. Her meal intake is not as good. She feeds herself but needs
encouragement to eat. I am not sure how my dietary recommendations from my notes get to the staff, so
they know what needs to be done for her. I did not see the documentation in the medical record about her
not eating the fortified cereal or health shake. I have not contacted the family regarding the resident's
weight loss. That is nursing's job. I did not update [R1's] care plan. That is my job, but I have not done it.
On May 1, 2023 at 12:30 PM, V16 (Physician) said, I was never notified of [R1's] significant weight loss.
With her dementia, there needed to be more close oversight. She needs one-to-one assistance with
feeding. Had I been notified of her weight loss; I would have been more hands on in the oversight of her
care. The facility has to ensure the person who is not eating is assisted in order to restore weight gain. I am
the Medical Director of the facility, and it is the facility's responsibility to notify the physicians of their
resident's significant weight loss. They must do that.
2. On April 26, 2023 at 3:58 PM, R3 was lying in bed sleeping. R3 appeared very thin, with protruding
cheek bones and collar bones. An open nutritional shake bottle was sitting on R3's bedside table, next to
R3. The bottle was open, and a straw was in the bottle. The liquid contents of the shake were visible up to
the top of the bottle opening and it did not appear any of the shake had been consumed by R3.
On April 27, 2023 at 12:35 PM, R3 was lying in bed. R3 was not able to be interviewed due to his cognitive
status. V11 (Spouse of R3) said she was concerned because R3 appeared to have lost a lot of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145699
If continuation sheet
Page 9 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145699
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara of Elgin
1950 Larkin Avenue
Elgin, IL 60123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Level of Harm - Actual harm
weight and no one had contacted her regarding his weight loss or possible interventions to prevent further
weight loss. He was eating pureed food for a while, and he did not like that. I brought in my own diet
supplement drinks and meal bars for him because those are his favorite. I did tell someone that he really
likes ice cream, but they don't always bring it to him.
Residents Affected - Few
The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including,
non-traumatic subdural hemorrhage, depression, altered mental status, dysphagia, unsteadiness on feet,
abnormal gait, lack of coordination, abnormal posture, cognitive communication deficit, aphasia, falls, atrial
fibrillation, dementia, and elevated white blood cell count.
R3's MDS (Minimum Data Set) dated March 21, 2023 shows R3 has severe cognitive impairment, is totally
dependent on facility staff for dressing and personal hygiene and requires extensive assistance with all
other ADLs (Activities of Daily Living). R3 is always incontinent of bowel and bladder.
On March 17, 2023 at 10:58 AM, V7 (Dietitian) documented R3's admission weight of 124.7 pounds,
classified R3 as underweight, and recommended a house supplement twice a day.
Facility documentation shows the following weights for R3:
124.7 pounds - March 13, 2023
107.2 pounds - March 22, 2023
111.4 pounds - March 29, 2023
106.4 pounds - April 12, 2023
The facility's documented weights reflect a 14.68 percent weight loss between March 13, 2023 and April
12, 2023. The facility does not have documentation to show R3's physician or family were notified of R3's
significant weight loss.
The EMR shows the following order for R3 dated March 17, 2023:
House supplement, two times a day, 4 ounces BID, may have Ensure, MedPass, or Two Cal.
The April 2023 MAR (Medication Administration Record) shows the following amounts consumed of the
supplement by R3:
March 17, 2023 9:00 PM - Drank 50 percent
March 18, 2023 9:00 AM - Drank 40 percent
March 18, 2023 at 9:00 PM - Drank 25 percent
March 19, 2023 at 9:00 AM - Drank 30 percent
March 19, 2023 at 9:00 PM - Drank 15 percent
March 20, 2023 at 9:00 AM - Drank 30 percent
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145699
If continuation sheet
Page 10 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145699
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara of Elgin
1950 Larkin Avenue
Elgin, IL 60123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
March 20, 2023 at 9:00 PM - Drank 0 percent
Level of Harm - Actual harm
March 21, 2023 at 9:00 AM - Drank 50 percent
Residents Affected - Few
March 22, 2023 at 9:00 PM - Drank 0 percent
March 26, 2023 at 9:00 PM - Drank 50 percent
March 27, 2023 at 9:00 PM - Drank 40 percent
March 28, 2023 at 9:00 PM - Drank 30 percent
April 5, 2023 9:00 PM - Drank 50 percent
April 14, 2023 9:00 AM - Drank 50 percent
April 15, 2023 9:00 AM and 9:00 PM - Drank 0 percent
April 17, 2023 9:00 PM - Drank 50 percent
April 18, 2023 900 PM - Drank 50 percent
April 19, 2023 9:00 PM - Drank 0 percent
April 21, 2023 at 9:00 PM - Drank 25 percent
April 23, 2023 at 9:00 AM - Drank 0 percent
April 23, 2023 at 9:00 PM - Drank 50 percent
April 24, 2023 at 9:00 AM - Drank 50 percent
April 29, 2023 at 9:00 AM and 9:00 PM - Drank 50 percent
April 30, 2023 at 9:00 PM - Drank 25 percent
R3's care plan initiated on March 17, 2023 shows, Resident is at risk for alteration in nutritional status. R3's
care plan has multiple interventions initiated March 17, 2023, including consider finger foods, elevate head
of bed during feeding or meals if indicated, monitor for signs and symptoms of dehydration and weight loss,
monitor resident with difficulty of chewing or swallowing, assess for signs of choking and/or aspiration,
obtain labs as ordered, obtain weight as ordered, offer extra fluids if not contraindicated, provide assistance
for meals if indicated, provide diet and supplements as ordered, and provide good oral hygiene. As of April
26, 2023 at 3:37 PM, the facility did not have documentation to show new care plan interventions were
initiated following R3's significant weight loss.
On April 26, 2023 at 1:45 PM, V7 (Dietitian) said, she was not aware R3 was not drinking his nutritional
shake as ordered and she does not review the MAR to check for the resident's amount consumed of the
nutritional shakes. V7 continued to say she has not attended any meetings at the facility
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145699
If continuation sheet
Page 11 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145699
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara of Elgin
1950 Larkin Avenue
Elgin, IL 60123
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
regarding resident's significant weight loss.
Level of Harm - Actual harm
The facility's Weights Policy revised 5/19/2022 shows: Policy Statement: It is the facility's policy to obtain
resident's monthly weight unless otherwise ordered differently by the physician. For a resident who is on
dialysis, the resident's dry weight will be also obtained monthly. Procedures: .3. The significant weight
changes (monthly 5%, quarterly 7.5%, and every 6 months 10%) will be assessed and addressed by the
IDT (Interdisciplinary Team) which includes but not limited to the Dietitian, Physician, Medical Specialist,
Speech Therapist, Nutritionist, and Nurses.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145699
If continuation sheet
Page 12 of 12
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
FAQ · About this visit
Common questions about this visit
What happened during the May 3, 2023 survey of The Pearl of Fox River Valley?
This was a inspection survey of The Pearl of Fox River Valley on May 3, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at The Pearl of Fox River Valley on May 3, 2023?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a t..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.